Patients with axial spondyloarthritis have high rates of depression, with almost one-third experiencing moderate-to-severe symptoms, a cross-sectional German study determined.

Among a cohort of 1,736 patients, 31% had scores of 28 or lower on the World Health Organization Well-Being Index (WHO-5), indicating possible moderate-to-severe depression, according to Denis Poddubnyy, MD, of Charité Universitätsmedizin in Berlin, and colleagues.

An additional 28% had WHO-5 scores of 29 to 50, suggesting mild depressive symptoms, giving a total of 59% of patients reporting some degree of depression or impaired well-being, the researchers reported online in Annals of the Rheumatic Diseases.

Axial spondyloarthritis is a chronic inflammatory disorder affecting the spine, with various extra-articular manifestations including inflammatory bowel disease and psoriasis. It includes both radiographic and nonradiographic subtypes, depending on whether inflammation of the sacroiliac joints can be detected.

Psychological distress and depression have frequently been reported among these patients. To assess the extent of these concerns and to identify potential contributing factors, the researchers analyzed data from a nationwide health insurance database for the years 2013 and 2014.

The analysis included patients with axial spondyloarthritis who completed a questionnaire about disease, psychological factors, lifestyle, and socioeconomic status. The WHO-5 index includes questions about feeling cheerful, calm, active, well rested, and interest in daily life, with scores above 50 indicating well-being and no depression. Disease activity was assessed with the Bath Ankyolosing Spondylitis Disease Activity Index (BASDAI), and functional status with the Bath Ankylosing Spondylitis Functional Index (BASFI).

The mean WHO-5 score was 44.70 in the patients, compared with a mean of 69.95 in the German general population, ages 41 to 60.

Significant differences were seen among patients in the three WHO-5 groups (no depression, mild symptoms, moderate-to-severe depression). For example, BASDAI scores were 3.3 in the no depression group, 4.8 in the mild group, and 5.8 in the moderate-to-severe group (P<0.0001), while BASFI scores were 2.9, 4.2, and 5.6 (P<0.0001).

The moderate-to-severe group also more commonly reported having inflammatory bowel disease and psoriasis, and less frequently were fully employed and had high household income. Low WHO-5 scores also were associated with smoking and a lack of exercise, and patients in that group reported significantly more "suffering from stress" (52.6% versus 25.5% in the no depression group, P<0.0001).

Among patients with moderate-to-severe symptoms, the use of disease-modifying anti-rheumatic drugs and biologics was not significantly higher than among the mild or no depression groups, but they did more often receive nonsteroidal anti-inflammatory drugs, steroids, and analgesics including opioids, as well as antidepressants, anxiolytics, and hypnotics. Fibromyalgia also increased in incidence with more severe depressive symptoms.

On a multivariate analysis, these factors were independently associated with moderate-to-severe depressive symptoms:

Higher BASDAI: OR 1.37 (95% CI 1.27-1.49)

Higher BASFI: OR 1.25 (95% CI 1.17-1.33)

Lack of exercise: OR 1.50 (95% CI 1.14-1.98)

Suffering from stress: OR 2.03 (95% CI 1.55-2.64)

Household income below €1,500 ($1,860): OR 1.88 (95% CI 1.27-2.78)

Household income below €3,200 ($3,970): OR 1.54 (95% CI 1.08-2.19)

Neither sex nor age was associated with moderate-to-severe depression, however.

The study suggested that a substantial number of patients with axial spondyloarthritis experience depression, which could influence pain and other outcomes. The higher BASDAI and BASFI scores in the moderate-to-severe group could also reflect more severe disease, which in turn could worsen depression.

And while factors such as lack of exercise and perception of stress could be either a cause or a consequence of depression, they are potentially modifiable and could benefit from intervention.

The frequency of depression in these patients "is also clinically relevant in the context of new drugs currently under investigation for the treatment of axial spondyloarthritis, which might worsen depressive symptoms and/or provoke suicidal behavior like apremilast, a phosphodiesterase-4 inhibitor, or brodalumab, a monoclonal antibody against the interleukin-17 receptor," the authors cautioned.

"These findings highlight the need for the careful evaluation of depressive symptoms as a part of the management strategy for axial spondyloarthritis, helping to improve axial spondyloarthritis outcomes," they concluded.

Study limitations were its cross-sectional design and reliance on claims data.

The study was funded by Germany's Federal Ministry of Education and Research and by the Leibniz ScienceCampus Chronic Inflammation.

Poddubnyy and co-authors disclosed no relevant relationships with industry.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco

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